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Women and Economic Reform in India: A case study from the health sector

Malavika Karlekar

Introduction: The Premises of Economic Reform

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n 1991, under the overall rubric of economic reform, the Government of India put into operation a set of wide-ranging policies and programmes. While some of these had been on the anvil from the mid-eighties onwards, it is only in the present decade that several measures were initiated with a certain determination. However, the reform package has had

a mixed response, with considerable apprehensions of how these are going to affect certain sectors of the population; various people's movements including the women's movement have been greatly concerned with some aspects of globalisation and how it will affect the less privileged. For instance, the introduction of Free Trade/Zones has generated the need for cheap labour; but what will more, low paid jobs mean for women's status? With increasing competition and the thrust towards already over-crowded urban centres there will be an increase in crime and violence; how will women - major pillars of the national as well as individual family economies - cope with more stress and tension? Thus, before analysing the implications of the reform package, it is important to look at some basic parameters of Indian women's lives today. As we proceed, it will be clear that women's health and well-being - the focus of this paper - are intrinsically linked to other aspects of their status. For most of this century, the decennial Census operations have recorded an adverse sex ratio for women: it declined from 934 females for a 1000 males in 1981 to 927 in 1991. Coupled with increasing information on foeticide and infanticide, it is clear that the Indian girl child and later, woman - is the subject of discrimination and prejudice. The prevalence of a dominant family ideology which strictly demarcates definite roles and obligations for girls and women leads to their devaluation and marginalisation. The basic assumption. is that girls are inferior, physically and mentally weak, and above all, sexually vulnerable. In a society which lays so

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much stress on purity and pollution, various oppressive structures - including early marriage are encouraged so as to restrict feminine mobility and freedom. Not unexpectedly, then, access to various resources such as education, health care and nutrition as well as parental love and care are determined by a range of factors. That fifty years after independence, only a little more than a third of women are literate, is indicative of the overall attitude towards women and their roles. In addition, in keeping with the world-wide trend on exposing such data, information on violence against Indian women and girl children has brought into focus their extremely fragile position , both within the family and in public spaces (Karlekar et al 1995). Yet, there has been slow progress in certain vital areas: female life expectancy at birth has risen, the sex differential in infant Mortality Rates is almost bridged, and an increasing number of women are joining the work force. The chief achievements of the last decade - and certainly among the most important features of the postindependence period - have been the 73rd and 74th Constitutional Amendments of 1993 which reserved 331/3 percent-,of seats for women in elections to local bodies in both the rural and urban areas. The outcome has been a virtual revolution in the political scenario of independent India: it is estimated that when elections are completed in the 21 states of the Indian union where the Amendments are applicable, over 1 million women will have been elected to these local bodies. However, clearly traditional holders of power are unhappy with this shift in focus: a recent report (The Hindu, New Delhi, April 9, 1997) from Rajasthan, a state notorious for negative female development indicators, quoted two women sarpanches or heads of Panchayats (villagelevel elected bodies) as saying that they had been impeached by the male majority because of resentment against their development-oriented plans and drive against corruption. In other words, the patriarchal order will resist what it feels are invasions of its bastions of power and authority. Against this backdrop, it becomes important to assess how drastic economic reforms will affect women's lives and well-being. In other words, the paper argues that State policies and programmes are for and about people: however, given the irrevocable mandate of globalisation on the one hand and internal economic decline on the other, it has at times been all too easy for the Indian State to concentrate mainly on overall strategies to face such challenges. In the process, blueprints for progress often overlook the claims of those negatively affected by such changes. It is then left to the voices of dissent to narrate a cautionary tale: the democratic polity represents an increasingly aware electorate, one which is not only concerned with individual rights but which also has certain expectations from a State poised to enter the global

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by encouraging privatisation of health care often as we shall see. The newly elected government adopted a mixedeconomy approach: while the public or government sector was to handle major responsibilities such as power. Further. Economist Pranab Bardhan has commented that while there was "some general progress over the years in the provision of public consumption and welfare measures for the poor" (Bardhan 1984:4). steel.:4). during a financial crisis. He identified low investments. India was "a low productivity agrarian economy" (Krishnan and Rao 1995:3). While by the mid-eighties there was a re-thinking on economic policies. in the post-independence period. if political structures are to endure they have to move beyond the narrow confines of contractual relationships (see Fiona Robinson [1997] for a discussion on how global politics must incorporate an ethics of care based on a commitment to people and not only policies)-. For. The following analysis of health care in India shows how the State has not taken into account the implications of its policies. it was the crisis of 1990-1 which "shook the very foundations of Indian development strategy and planning" (Krishnan and Rao 1995:7). a million children die each year from diarrhoeal diseases (Shiva 1995:114). in fact. spiralling inflation and impending balance of payments crisis had to be tackled.economy. By the seventies it was clear that economic policies had not been able to contain inflation nor deliver social justice: if the low rate of growth. "the axe falls most heavily on the social welfare programmes for the poor"(ibid. 185 million have no access to drinking water and while the government claims that 80 per cent of villages have safe drinking water. At the time of independence from the British in 1947. a fresh look at existing strategies and programmes was necessary. by default . That. the Indian State is increasingly adopting a minimalist position as it labours to keep at bay divisive forces and growing discontent. According to the authors. mines and heavy industries. the crisis was triggered by the. Gulf War 3 . there was enough evidence to suggest that poverty alleviation measures were not taken too seriously. the absence of an adequate administrative machinery as well as organisational and managerial bottlenecks as being responsible. food grain production. The mixed economy philosophy and Five Year Plans defined priorities and allocations maintained through an elaborate system of licensing and quality control which regulated the latter. In the years before the current phase of reform. these remained woefully inadequate.it is reneging on its contract with its citizens: far from an ethics of care. the manufacture of consumer goods as well as some capital goods were controlled by private enterprise. investment and planning for the social sector has not been given the attention necessary for a country of India's size and dynamics is evident by a quick look at some figures: half a century after independence 130 million people in India do not have access to any kind of health facilities.

For instance. He concludes that an agriculture-led growth is likely to be faster and the spread effect of growth will be more "if it is accompanied by investment in infrastructure and in human resource development"(ibid. and. liberalisation and globalisation (Krishnaraj 1993). withdrawal of subsidies.:406).69) points out that it is vital to critically assess the composition of terms such as 'growth' and 'output'. see Also Mathew 1995 Panini 1995. have.Vyas argues that this trickle down theory is based on certain premises which may not be valid. While advocates of the reform package do not rule out intervention on behalf of the poor. others (Krishnaraj 1993) feel that the situation was in fact in the making due to a faulty import policy and other related factors brought about by political exigencies. in health care. as we shall see.when. costs of health care shoot up. the country approached the International Monetary Fund and the World Bank for "extraordinary accommodation". privatisation. not only does the rate of growth have to be high .between 6-8 per cent . The philosophy of open competition and privatisation has substantially permeated the social sector. In other words. when combined with a de-regulated drug market. With few other options. due to a number of factors. All of these. However. The incumbent package of economic reforms consisted of the four strategies of devaluation. a skewed growth rate which boosts the consumer market is unlikely to benefit the underprivileged. affected the life of the average household in a number of ways. the funding institutions. Analysing such economies Ajit Kumar Singh has pointed out that there has been a fall in standards of working class populations with the slowing down of employment opportunities. S. rise in the price of public services as well as contraction of government expenditure(Singh 1993. Zambia. they assume that "the really effective weapon for poverty alleviation is accelerated economic growth ' (Vyas 1993:406). including a drying up of foreign remittances from the Middle East. the country's foreign exchange reserves shrank to "the value of a single month's import bill"(ibid. V.but also the composition of this growth is vital. Arguing that "structural adjustment may have limited impact in terms of augmenting growth" but "will have disastrous social consequences on the long-term development of the nation" Maithreyi Krishnaraj (1993. as happened in the Dominican Republic. in one way or another.:9). Pathy 1995). a history of unsatisfactory state-run facilities has led to the burgeoning of the private sector. made stabilisation and structural Adjustment conditional for the receipt of such assistance. As a 4 . Brazil and other Latin American countries. A sudden rise in the cost of living can result in widespread protest and often violent rioting. In the post-reform period this tendency is exacerbated. Evidence from other economies which have gone through this kind of reform indicates that the need to reduce fiscal deficits has forced Latin American countries to cut back on subsidies and certain kinds of social expenditure. in turn.

While agreeing that during structural adjustment "the burdens on poor women . population lived below the poverty line. In structural adjustment programmes. to re-orient strategies to combat the crisis.:8-9). poverty in India has been a major issue in the post. A certain amount of speculation on the future of reform followed.H. governments have been forced to undertake ameliorative measures.economic structure. . A clear statement on its approach was enunciated in the Common Minimum Programme document which stated that the Front is committed to giving the Indian people "a higher standard of living and a better quality of life through faster economic growth and enhanced social justice" (CMP 1996). subsidised essentials such as food grains. have increased" economist Diane Elson nonetheless points out that it is important to know whether it is the programmes themselves which add to the burdens or whether there is a need to look more closely at the economic crisis which resulted in the programme. a third of the.7 as against around 35 per cent in the earlier years. as well as items of daily consumption. economic reforms have only heightened certain existing negative trends through unimaginative strategies which do not take into consideration the needs of the people.. For instance.consequence.. In the general elections of 1996. prereform period and in 1991. C. a rise in agricultural production and real wages. cooking oil and fuel. the Congress Party which had initiated economic reforms in 1991 was voted out of power. Arguing that "growth with social justice will be the motto of the United Front government". the CMP further reiterates that as "there is not substitute for growth. Thus. Hanumantha Rao and Hans Linneman (1996) have drawn attention to the fact that absolute poverty has increased in the immediate post-reform period even though these years witnessed good harvests. 1996:27). the safety net component focuses on enhanced social sector spending. the country's GDP needs to grow at over 70/o per year in the next ten years in order to abolish endemic poverty and unemployment'(ibid. to the shock of adjustment' (Hanutnantha Rao and Linnemarn. what is significant is that not only did a crisis exist but it was exacerbated by a) certain retrogressive measures and b) an inability. This is evident if we take into account that the percentage of those living below the poverty line for 1992-3 had gone up to 41. Accordingly. especially in rural areas. being initiated (Elson 1994:149). In other words. They conclude that this situation could have been avoided "if the policy package and the measures adopted had taken due account of the vulnerability of the prevailing socio. according to certain socioeconomic parameters. . the update on the Economic Survey presented to Parliament in July noted that though the growth rate of 7% is 5 .independence. particularly when the coalition United Front government took over in May.

the Indian states. forestry and fishing which support the bulk of the population recorded an extremely low rate of 2. actual implementation falls far short of people's needs.viewed broadly as a state of mental and social well-being.reassuring.preventive. curative and promotive . The many voices from the women's movement as well as from other broad-based people's movements fractures the. Not unexpectedly. this paper examines the health sector with a view to highlighting myopic policies and faulty implementation strategies. rather than the Central government have a primary obligation for these two aspects of civic life. trickle-down theories of development and naive belief that the social sector can take care of itself. admitted to limited success in bridging the gap in the population's access to basic rights such as education.4%. under the federal system of governance.is a part of the current Indian development literature. women and children (particularly those from underprivileged homes) are: easy victims of inadequate delivery systems and outreach programmes. on the other hand. The Constitution of India placed public health and sanitation in the state list. health. down priorities and directions. Recognising that "existing special programmes for employment generation and poverty alleviation need to be strengthened". people who "are our most valuable resource" 6 . to be regarded as a human and civic right. school enrolment and medical care lag far behind those of most East Asian countries". with 'varying degrees of candour. this was due mainly to industrial production. the provision of basic health services is the responsibility of the State. sanitation and so on. agriculture. in other words. the document spoke in vague generalities about improving programmes for education and health. housing. one which questions the votaries of liberalisation. Nor has civil society been silent on the declining role of the State: for instance. discourse on liberalisation by providing counterpoints and critical appraisals of avowed promises and preferred solutions. nutrition. in this paper health is. While the idea of holistic health . According to a recent policy document the Government of India admits that as human development indicators such as "life expectancy. In India. By doing so we hope to contribute to an alternative discourse. Accordingly. from 1975 onwards. An Overview of the Health Scenario in India In keeping with the World Health Organisation's definition. where the Five Year Plans lay. the women's movement has drawn attention to certain negative socio-economic trends and how these affect the status of women and children. their expectations of the market. literacy. Most official documents in the fifty years of India's independence have.

control of communicable diseases such as malaria. While the "private health markets" served two thirds and more of the sick in Uttar Pradesh. private hospitals/clinics will be supported'. which was conducted across 6. For instance.. tuberculosis. nutrition. Selvaraju of GDP health. leprosy. Reddy and V.. only 22 per cent of the population in Kerala. Pointing out that education and health care of the privileged have skimmed off a major share of budgetary allocations in these areas. 37 per cent in Bihar and 38 per cent in Maharashtra used public health facilities (Shariff 1995:17). established the importance of the private sector in health care. the document argues for a redirection of priorities which will lead to "much higher shares of the budgets for education and health on primary education. the total expenditure on medical and public health declined from 62.14% of the relevant budgetary head to 48. Bihar and Madhya Pradesh.. Kerala and 7 .should be "at the centre of our strategy of economic reform" (GOI 1993b:26). This rationalisation for a minimalist State position in health care is born out by the findings of a nation-wide survey conducted by the National Council for Applied Economic Research to establish the market structures for a variety of consumer good. the Central Plan outlay for programmes of the Department of Health has been stepped up from Rs. while salaries accounted for a large percentage of the outlay.all clubbed under the health budget increased. equipment and fuel were inadequately -funded (Duggig 1995).354 rural and 12.N.670 crores in the 1995-6 period.62% (Reddy and Selvaraju 1994). 30 per cent in Madhya Pradesh. Not surprisingly then. high birth and fertility rates are identified as major actors in this scenario of declining well-being and productivity: the document states quite. It is also important to note that during the period 1974-5 to 1990-1. unequivocally that "the effectiveness of the family planning programme will need to be greatly improved" particularly in the high birth rate states of Uttar Pradesh. the Eighth Plan document also emphasised that "in accordance with the new policy of the government . In addition. 421 crores) as well as salaries and maintenance (GOI 1996). This has meant the rapid growth of the private sector in health care. basic health care and women and child welfare". The Economic Survey presented to the Parliament in 1996 states that after the introduction of economic reforms. A large percentage of these funds are ear-marked for the. 302 crores in 1992-3 to Rs.339 urban households in 1992-3. The survey. and collected data on morbidity. water supply and sanitation . blindness and now AIDS (Rs. A longitudinal analysis by K. non-salary components such as medicines. 27 per cent in Uttar Pradesh and West Bengal. expenditure between 1974-1991 indicates that though spending under the heads of family welfare. health care utilisation and health expenditures in considerable detail. Not unexpectedly. that of medical and public health declined.

Andhra Pradesh.6 per cent of the PHCs had properly equipped operation theatres. Madhya Pradesh. and Rs. there was already a crisis in the State-run health sector prior to 1991. the share of private hospitals in the last two states is also considerable. A recent Indian Council of Medical Research (ICMR) study on family welfare services at the Primary Health Centre level observed that only 22. 2611 for a public hospital and Rs.7 in 1951). field studies show that not only is there a concentration in certain states. In addition. it should not dominate government thinking nor allocation of resources to the detriment of the underprivileged sectors of the population who neither have secure jobs nor access to facilities. In short. Though the number of Public Health Centres went up almost three and a half-fold between 1981-91 as against the one and a half-fold increase between 1971-81. it is important that these should function effectively. almost 50 per cent of sub-centres.000 population (as against 1. then.:49). Orissa. did not have buildings of their own. underutilisation and in exacerbating already existing inequalities and imbalances. inadequately staffed and too far from the target population. Further. Given that the public health system works through sub-centres. water supply was safe in only 71 per cent of the PHCs evaluated (ICMR 1991: 17. but also that the large majority of centres are ill-stocked. Not unexpectedly. While we acknowledge that this is a responsibility of the State. the survey found that the poorer households spend 7-8 per cent of their household income on health care as compared to the 2 to 3 per cent spent by the richer households. The study also noted that per capita expenses were much higher when individuals used private facilities: for instance.much thought being given to changing needs results in wastage. Uttar Pradesh and West Bengal. The number of medical practitioners in 1991 was 4. Karnataka. If we juxtapose infant mortality and poverty 8 . a good percentage of the Central budget on health goes on providing services for its employees through the Central Government Health Scheme (CGHS). Maharashtra.7 per 10. a mere enhancement of funds which are allocated without. in a majority of PHCs in Bihar. Primary Heath Centres (PHCS) and Community Health Centres (CHCs). Jammu and Kashmir. 1.115 for a private hospital. 36 and Rs. Thus. Rajasthan. Kerala. all-India per capita health expenditures on fees and medicines only for hospitalised and non-hospitatised medical episodes based on data from selected urban areas in a number of states was Rs. PHCs in most parts of the country are ill-equipped.81 for non-hospital expenses in the public and private sectors respectively(ibid. however. PHCs or CHCs. Tamil Nadu. operating theatres were not properly equipped. 19). A recent evaluation of the public health care infrastructure in the country noted that the system which "caters to the needs of 25-30% of the population is grossly deficient" (Government of India 1996b).

). Thus. The Eighth Plan went on to point out that it is not only the rural poor who are deprived: in large cities. "the health system has yet to 9 . we find that the states of Uttar Pradesh. much of a woman's ailments are related to her reproductive history. of these Bihar. is more a health hazard than a natural function" (GOI. Orissa. Further. Gujarat. Further. n. a recent government document points out that "biases in. lack of facilities and high infant mortality rates are vitally linked. Thus. if not worse than in rural areas".care facilities rather than primary. In a situation where about two.figures with the dismal picture of PHC facilities. Not unexpectedly. it is not difficult to envisage how the rest of the money is spent. It is not surprising. constituted major impediments to full utilisation of these units" (GOI 1993a:206). Madhya Pradesh. pointed out that demographic indicators suggested that "child bearing in India. In other words. 200 months or 50 to 60 per cent of the time are spent in pregnancy and lactation" (Gandhi and Shah 1992 : 104. "the infrastructure for primary health care in urban areas hardly exists" (VHAI. On the whole then. The increasing withdrawal of the State from a vital sector of developmental activity means that health care for a growing proportion of the population depends on private institutions and individuals. 1975:315). Assam-. then. for the majority of women. women's heavy domestic-cum-work burden also makes them prone to a range of ailments. Madhya Pradesh. shortage of drugs. equipment etc. Studies have shown that the chief beneficiaries of domestic expenditure on health are men and children. where about 40-50 per cent of urban dwellers live in slums. favour of curative vis-a-vis preventive and of secondary and tertiary health . Towards Equality.thirds of the total health expenditure goes on personnel. the Report of the Committee on the Status of Women in India. Apart from this. their health status "is as bad. in 1975. quoting Jaya Rao and Kamala:). Women as Reproducer: The Dominant Image When.d. This led the Government of India to admit that "the lack of buildings. Rajasthan and Bihar had above average Infant Mortality Rates (IMRs). that recent health expenditure studies show that household expenses on medicare is three to four times that of the government's total health expenditure. it was recording an unpalatable fact of life: the average woman becomes pregnant about six to eight times within the 15-45 year age group. poverty. Orissa and Uttar Pradesh had a larger population living below the poverty line. as Srilatha Batliwala points out the national health system is geared towards viewing the woman as mother and reproducer. need to be corrected" (GOI 1994:153). "of the total 360 months of reproductive life. then.

. n. 34 per cent in Madhya Pradesh.20. the public health sector's major concern vis-a-vis women is to prevent them from becoming mothers (Duggal 1996:2). A study (Ramalingaswami 1987) of women's access to health care in the economicallybackward Vishakapatnam district of Andhra Pradesh which had a substantial tribal population showed that maternal and child health services. Two programmes which did reach the women were the National Malaria Eradication Programme and the family welfare schemes.. Again only 15 per cent of such centres had the required number of health personnel and there was an acute shortage of Lady Health 'Visitors (LHVS) (ICMR 1991:1 1). 23.. 67 per cent of the women knew of the PHCs and had used them particularly when they had accidents or there was a serious illness in the family. When the facilities are not available.442 and 29. Even for these limited programmes "health workers and infrastructures. So far. of the needs of 1.000 individuals. are grossly inadequate and of poor quality". As Ravi Duggal has noted Both the private and the public health system's core attention towards women is viewing the latter as mothers. a single PHC takes care. were. a study of users and non-users established that 65 per cent of non-users said that the services were poor. at the time. are too far away'. namely men. The NCAER study showed that 39 per cent of all rural patients in Himachal Pradesh.63-5). This attitude finds expression in inadequate sensitivity and training in non-maternity related health care issues as also in ill-equipped facilities and programmes.waken to the fact that there are a large number of women in need of health care who are neither pregnant nor lactating" (Batliwala. Further. In another study (Murthy and Barua 1995) of Pamer block in 10 . 55 per cent found distances too great and another 16 per cent complained of non-availability of medicines. almost non. difficult terrains and inadequate transport facilities further exacerbate a reluctance to use the formal network (Visaria and Gumber 1982). Yet. Punjab. the requisite government ratio is one PHC for a population of 30. In many of the less developed states. to use them. when it is a question of using private facilities. Distance of facilities. the expenses may be such as to allow only the more privileged family members. Dissatisfaction among users was also high (Mukhopadhyay 1993 . and the personnel is unsympathetic . According to recent statistics.243 persons respectively. Kerala and Maharashtra had one PHC for a population of 6.d).existent in the tribal areas of the state. Though awareness of the official health care system is high. 31 per cent in Tamil Nadu and 26 per cent Karnataka had to travel more than 10 kilometres to reach the nearest hospital for Out Patient (OPD) facilities (Shariff 1995: 17).000 (George and Nandraj. the opportunity costs in missing out on daily wages is too great. While the private nursing home sector comprises of maternity homes. 1993).928.

deliveries by Trained Birth Attendants (TBAS) and immunisation services was much higher in PHC headquarter villages. the PHCs function through LHVs and ANMS. a woman suffering from malnutrition "has to go through about eight pregnancies to have five births (of which only three or four may see adulthood). Consequently. the government is planning to contract private practitioners (Pachauri 1995). In this context. For maternity and family planning activities. For instance. while the figure rose to over 80 per cent in sub-centre and remote. This fact is reflected in the following figures from the ICMR study: 55 per cent of deliveries in villages with PHCs were domiciliary. the percentage of such women receiving iron and folic acid tablets as well as tetanus toxide injections is quite low.wife (ANM) is the only staff member present and it becomes difficult to recruit women physicians in the rural areas. Thus it would be safe to surmise that in all parts of India. Often the Auxillary Nurse Mid. a substantial number take place without any attendants (VHAI 1992:269).Ahmednagar district of Maharashtra established that the overall coverage by maternal health services such as ante-natal care. it is important to note that well over 60 per cent of births are' domiciliary in nature. Even when the physical structures are present. Not unexpectedly. An evaluation of 398 Primary Health Care Centres in 199 districts in 18 states and one Union Territory by the Indian Council of Medical Research (1991) for the availability of antenatal. and the outreach of personnel unsatisfactory. this led the report to conclude that "for a long time to come intranatal care will have to be provided on 11 . coupled with overall malnourishment and unfavourable socioeconomic conditions. In addition. pregnant women are prone to miscarriages. the percentage of domiciliary births could be as high as 90 per cent (VHAI 1992). the network of Community Health Centres record and deal with only a small percentage of pregnant women (Mathai 1989). exposing herself to potentially grave consequences each time" (Shiva 1992: 276). postnatal and neonatal care established that facilities and service's were inadequate. As a result. anaemia is high: over 50 per cent of normal women and 65 per cent of those pregnant suffer from caromic anaemia (Shiva in VHAI 1992 : 282. In fact the dais are the linch-pin of childbirth practices in India. Among tribal communities. Traditional Birth Attendants (dais) "form a crucial and important segment of primary health care system" (ICMR 1991:1 1). excessive bleeding and infection. Such villages are few and far between and CHCs are inadequate. see also Mathai 1989 and World Bank 1996 for a detailed discussion). intranatal. in order to meet the shortage. stillbirths. the absence of sufficient medical facilities is increasing the dependence on private medical care. and of these. In other words. staff shortage is endemic. Not surprisingly then. villages.

non-institutional basis". Both are geared to the achievement of a Net Reproduction Rate (NRR) of unity by 2016 A. the need to have someone to go with and an overall belief that "we will not be treated as humans".:24). paying for a companion and the cost of food. Visaria and Gumber 1992 and VHAI 1992 ) also all point to the fact that the majority of Indian babies are and will continue to be born at home. In subsistence-level economies children are treated as commodities "who not only compete for 12 . 1994). In a study in a Maharashtra village. This fact brings into sharp focus three points: first. Distance of the Centre.D. population initially increases rapidly because the mortality rate declines well ahead of the fertility rate" (Palmer 1991 : 53). Another important factor was the requirement of an attendant at the hospital or Centre: this meant that either the husband or someone else. through the network of dais(ibid. By and large. Lack of child care facilities meant that for the time that the mother was away. i. of late. Gupta and Borker 1987. the need to strengthen the indigenous system. Further. Information available from other studies (Chanda 1988. Both reproduction and reproductive health become major talking points in structural adjustment programmes as a fast growing population is viewed as being detrimental to economic development (GOI 1993a. made -for other children. distance. out of 131 births in seven years. In addition to a fear of unsympathetic staff. Mathai 1989. cotton wool and so on could as well be used for food and essential commodities at home. there is also a fear of being coerced into sterilisation (Chatterjee 1989. The ICMR study confirmed the lack of many basic medicines in the PHCs resulting in patients having to buy them in the open market. Not unexpectedly then. It is important to understand fertility and reproductive behaviour during a period of economic transition as is the case with India today. While women seemed willing to go for prenatal check-ups to PHCs and municipal dispensaries.e. a reluctance to use these facilities and third. they drew the line at institutional deliveries. would have to take time off from work to be on duty in the hospital. "during the transition. only one delivery was conducted in a PHC. There were several women who went to the PHCs or nearby hospitals for prenatal check-ups and tetanus toxide inoculations. many women felt that money which would have to be spent on medicines. injections. medicines and other necessities led women to deliver at home. Quadeer 1986). Even when facilities are available why do Indian women prefer to have their babies at home. arrangements had to be. second. 1993b. Chatterjee 1983. quite often attended to by barely competent helpers? Lack of faith in the public system is accentuated by shortage of medicines. the State has decided to intervene more actively in reproductive control -through (a) disincentives and (b) experimenting with a range of new female-oriented contraceptives. inadequate institutional facilities.

As a result. a direct intervention in a very sensitive area of their lives is significant. In other words. namely improved and extensive child care and school facilities and access to health care. however. child mortality rates are of crucial importance. Clearly. has to work out carefully its policies and plans for implementation. There is evidence from developing countries that with an initial rise in incomes. As already pointed out. the scope for choice-making. as the primary agency for effecting population control. it is still extremely high.the State is seeking to intervene in her life through a series of invasive measures. the State is a selective interventionist. Equally evident is the fact that in order to have an impact. though the infant mortality rate which is around 73 per 1000 is declining every year. The current thinking in family welfare and birth control strategies in India is an excellent testing ground for notions of intervention. While the State has not felt obligated to act to improve the working conditions of the majority of women. population growth has been identified as a major hindrance to economic development: A recent official document on the economic scenario has zeroed in on population growth as a "critical problem".:59). In India. Again there are important cultural factors such as producing sons for the lineage. the controversial issue of reproductive control and concomitant strategies impinge directly on ethical problems such as who makes the decision.scarce resources" but also help in the generation of these as well as of disposable income. its enthusiasm over new contraceptive technologies. the Department of Family Welfare has identified 90 poor performing districts" . "to provide special inputs". Rajasthan and Uttar Pradesh. There is little evidence. fertility increases. An important input into all these debates is the employment status of the. only to decline later.83 of which are in the BIMARU states of Bihar. boundary maintenance and sense of individual identity. 13 . Even if it's accepted that due to the nature of women's work. the State.and hence respecting a woman's sense of self . Madhya Pradesh. of these being priority areas. This results in several conceptions so as to ensure between 2 and 3 living children. which influence reproductive decisions. It was proposed that the entire World Bank assistance available under the social safety net programme for family welfare for 1992-4 is to be used for these districts (GOI 1994: 149). Accordingly. through which the State can improve the quality of Indian women's lives. It is not difficult to link the sudden frenzy surrounding new reproductive technologies and structural reform. there are other areas. woman: while data from industrialised societies indicate that there is a negative relationship between female labour force participation and fertility. Under the guise of providing more choices . to woman's integral right to control her body and so on. Above all. the same is not true of many countries of the third world(ibid. the scope for intervention is limited.

respiratory and endemic intestinal problems as well as nervous disorders (Ghosh 1996). It is likely that with continued rural-urban migration. the mushrooming of unhealthy towns and cities and the degradation of the natural environment combined with jobs which increasingly concentrate workers in industries. Either as home workers and managers.women combine their innumerable roles often with little or no support from the State. means that the needs of the people have to be satisfied by the private sector: with the emphasis on privatisation. the range of diseases and illnesses will increase. Data from Sri Lanka which started on a programme of economic reform in 1977 indicates that an increasing awareness on health issues is coupled with the growing incidence of diseases associated with stress. but for growth which is the result of a well-thought out strategy based on an assessment of felt needs. unpaid family labour or as workers in the competitive gender-biased employment market. Expected help from family members shifts the responsibility disproportionately to female children. the marketised health sector is growing rapidly. In fact. In the context of the health sector it is important to look not for growth per se. putting. the role of producer seems to dominate over other functions because women are producing most of the time. women spend a major part of their lives in production. It is also one where interfaces between different situations have not been worked out. Nor is this neglect limited to research and analysis: the State has done little to improve the quality of life of those who constitute the backbone of many occupations and industries. essential for the growth of EPZs. particularly those of the cardio-respiratory kind (Gunawardana 1995). each with different health implications. 14 . Women's Health and Well-being in the Era of Reform We now look at some trends in the post-reform period. few look at the implications of hours of labour on a women's body and mind. stress-andenvironment related cardiovascular complaints. an increasing load on the family budget. while there is an abundance of women and work studies. however. Export Promotion Zones and sweat shops. This aspect of existence occupies much more space and time than do consumption and distribution. attempts at satisfying safety net requirements by focusing on targets and numbers and thereby pumping more money into physical infrastructures and salaries and not human resources. Women and their health will be adversely affected as they form the basis of the pool of cheap labour. as we have seen. The large majority of Indian women combine a multiplicity of roles. In this case. A similar pattern is emerging in India with the advent of tropical diseases like falciparun malaria and Japanese B encephalitis.

Growing dependence on the private sector in health is coupled with spiralling drug prices. researcher Mira Shiva has commented that while a majority of the 80. Clearly.:117). The following studies show how patterns of health care have changed in the post-reform period in some selected areas.at both the individual household. the Drug Control Authority is so over. with high percentages of child immunisation as well as institutional deliveries of babies. Among other things. and state levels one of the highest in the country but also it is the growing private sector which is being increasingly patronised. Due largely to foreign remittances. interestingly both these are major causes of mortality in developed countries. it is also a state where death due to vehicular accidents and suicide are high. the average family in Kerala is able to afford health care and medical attention. At the same time. the state also has a higher than average morbidity rate. the figures for which are well above the national average. Irudaya Rajan and K. 15 . Even before 1991. the New Drug Policy (1994) and the Drug Price Control Order of 1995 granted major concessions to the drug industry by way of reduced price and production controls (Shiva 1995).:1892). In a study of health status in Kerala. Not only is the consumer market flooded with drugsmany of which have registered a price increase of between 50-150 per cent after 1993 . and sickness prevalence has increased as the mortality rate has decreased. diabetes and disorders of the nervous system indicate that "diseases of poverty have been substituted by diseases of affluence".000 drugs in the Indian market today are spurious. ineffective and even hazardous. This seeming paradox is easily understood if we take into account changing perceptions of health with higher levels of literacy and awareness is well as an "excessive concern with the health of children and pregnant women".but also quality control has been an early casualty. Kerala was the best example of an Indian state with positive development indicators . S. James(1993) concluded that the increasing prevalence of deaths due to cancer. Health activist and. Citing data from developed countries the authors conclude that "the low mortality and high morbidity syndrome is not a paradox but a common rule"(ibid. dependence on the private sector is growing. it is the only state with a sex ratio favouring women and lower than average birth and death rates.and a high rate of use of available health facilities: female literacy is almost 90 per cent. At the same time. "the achievements of the state with regard to mortality decline can be heavily attributed to the utilisation of health services" (Irudaya Rajan and James 1993:1890). Recent surveys have shown that the state's population is extremely health conscious. due to an increasingly minimalist State presence. In keeping with the reformist ideology. whatever the cause. Not only is health expenditure .stretched that it cannot carry out basic quality control tests(ibid.

her vulnerability to gender discrimination. In other words.Mcneill's Food. laboratories. but also perceptions of health and general well-being improve.Apart from the gratifying conclusion that certain positive indicators lead to greater awareness of health and well-being.Gillespie and G.9 per cent for the same period." (Dreze. a self-interested private sector in health care is likely to take over. In the present context it is particularly alarming that most of the expenditure is in the growing private sector where unscrupulous doctors with their arsenal of medical equipment. the quality of the environment etc.:87). It need hardly be added that the entire public health system is not able to cope with the "increasing demands from a population which is conscious of the quality of care"(ibid. Our argument here is that there is enough evidence to suggest that with access to institutional facilities in either the public or private sector.rates come down. expenditure and consumption alone: for instance. While the internal dynamics and resources of a household are instrumental in determining entitlements. Another recent study of the post-reform period of 52 households in the semi-urban locality of Kozhikhode (Kerala) showed that the per capita medical expenditure has risen by 141 per cent in the 1991-4 period (Kunhikannan and Aravindan 1996). In his review of S. the inability of the State to satisfy a growing demand . the nutrition of a girl child. Health and Survival in India and Developing Countries Jean Dreze has drawn attention to the fact that nutritional status does not depend on standard economic variables such as income.will result in an increasing reliance on whatever facilities are available. her activity level and exposure to social stimulation. the number of her siblings. It is not difficult to extrapolate from the case of Kerala that in time the rest of India is likely to follow suit. not only do mortality and morbidity. is determined not only by household income and its uses but also by "the educational level of her parents. 1993:276). Health care together with nutrition is a household resource whose disbursement depends on perceptions of entitlements as well as the ability to satisfy these entitlements. in the contemporary Indian context it means that such services are available increasingly from the high cost private sector. This means access to as well as 16 . this rate was much higher than the overall consumer expenditure for all the households. however. what is even more disturbing is that even before other development indicators have caught up. the time-utilisation decisions of her mother. The expenditure on drugs per capita rose by 75.which may be caused by a combination of better awareness as well as an actual growth in disease and illness . scans and so on are becoming increasingly popular. certain exogenous factors either facilitate or hinder these decisions. tests.

ability to use institutions and opportunities which will increase the resource base . While these factors may act independently or interdependently. For instance. Among external factors which contributed to IMA were an above the national average state. being second only to the Seven Sister states of the North-east known for a high rating for women on most parameters. in this instance. the percentage population of Manipur which lived below the poverty line fell from 73 to 17. As already discussed. Emphasising that the context becomes very vital in determining IMA. that of Bihar remained more or less the sane . so as well. In 1981. a combination' of changed perceptions and available facilities led to an improved IMA. well below the national average 0f 110. occupational and marital status as determinants for infant survival. clearly.both endogenous as well as exogenous . there is a positive co-relation between health status and access to education.Shiva Kumar has constructed an Index of Maternal Advancement (IMA) (Shiva Kumar 1995). The female literacy rate of 28. Interestingly. clean living spaces and sanitation as well as the role of community organisations.29 per cent. Shiva Kumar drew attention to the fact that between 1971 and 1991.70 (India:31. The latter figure is hardly surprising and is likely to be the same in most other part of the country.which underpin entitlements. The following discussion will illustrate how child health is dependent on levels of maternal advancement which are determined by factors . the author concluded that there was an inverse relationship between the IMA and Infant Mortality Rates (IMR). Immunisation of children and births attended by either ANMs or TBAs were well below the national average (George and Nandraj 1993:1672).85 per cent is well below the national average of 39. while the national figure was 33 (Shiva Kumar 1995:75). emotional and otherwise . Kerala has a female literacy rate of almost 90 per cent.one of the highest in the country . delayed marriage. other variables were able to compensate for this absence. levels of education determine access of women to ante-natal care. all women with higher education did. Using the variables of women's educational. high female work force participation rate.to the household.K. and the IMA is 25. Looking at some selected health indicators we find that in 1987-90. Madhya Pradesh had a birth rate of 38.material. what is interesting is that the presence of other positive indicators encouraged illiterate women to 17 . while 85. of this percentage. expenditure on public health.60 (India:10.50) and a death rate of 13. the IMA for Kerala is 61.at over 65 per cent. In short.as against an all-India average for those years of 80. better nutritional levels.40) and an infant mortality rate of 119 . A.4 per cent of illiterate women went for regular check ups. infant mortality in Manipur was 32. On the whole however. for the same period. On the other hand. Shiva Kumar's case study of Manipur indicated a low level of female literacy. This is true not only of mortality data but also of morbidity patterns.

not unimportant among which is the cost of the facility. While states such as Kerala and Tamil Nadu "which have a strong political commitment to the goals of human development" had "protected" expenditure in the areas of health and education. information and communications. word of mouth communications through voluntary organisations and NGOS. in the present context. We would argue that it is of vital importance to understand the role of family and community traditions. Such an approach would also take into consideration that access to a facility is dependent on a range. The Central government together with the governments in the state share the financial burden of health care.utilise the existing health services. and in particular the girl child. and priorities are discussed across the table. An approach which takes into account voices from the grassroots is vital if the present crisis in the health sector is not to lapse into a phase of irreversibility. A study of 17 villages conducted to assess the impact of economic reforms on women's health indicated that women are now under increasing levels of stress and rarely have the time to visit a health centre or a doctor (Shatruguna cited in Ghosh 1996). Clearly the Indian State is dragging its feet in the social sector both at the level of allocation of funds as well in an assessment of priorities. local knowledge systems. Madhya Pradesh. through formal schooling. Rajasthan and Uttar Pradesh. and indeed the State. There is an urgent need then in the post-reform period to improve women's access to education. The question is. In other words. most Indian states "have shown no marked thrust on public health" (Seeta Prabhu 1995:249). NGOs and the National Literacy Mission.Seeta Prabhu concludes that in the post-reform period. this was not the case in the BIMARU states of Bihar. There is also information that these states have an above average annual increase of reported crimes against women. though women's lives are becoming more difficult and they are subjected to increasing degrees of violence within the home and at the work place. In doing so. 18 . As we have seen. it is limiting its competence in moving out of the endemic crisis situation in the social sector. on health status. informally through community groups. why is the State reluctant to make the safety net work? India is a federal structure where financial responsibilities are shared between the Central government and the states. K. of factors. In her comprehensive analysis of allocations. strategies and policies are not fine tuned to these realities. A look at how states allocate their funds for the social sector becomes relevant in this assessment of priorities. these were already the states with low levels of achievement in development indicators. it is of vital importance for the sustained health of not just the woman but also of her family members.

a meeting of government officials. it is clear from whatever data is available that unless safeguards are introduced. Yet. the economic pressures may compel households to resort to various difficult survival strategies". Nor is the safety net package going to perform miracles particularly if the net effect is a curtailment of services and a reduction of State initiative. NGOs. market forces are not sympathetic to sectors which 19 . the Government of India acknowledged that due to the new policies. should health care policy be governed by market forces or by the needs of the large bulk of its population who are unable to afford private medical attention ? Some Concluding Observations In the Country Report prepared for the Fourth World Conference on Women held in Beijing in 1995.) Concluding that more research and time were necessary before the impact of structural adjustment programmes on women could be assessed. look to the marketability of a product or service. "over-all. under the economic reforms of the Congress government led by P. access to it should be improved and not replaced by the private sector. thus. will it empower the State to do more for the disprevileged? At the same time.:451). at one point of time or the other. Policy and Finance Strategies for Strengthening Primary Health Care Services. the question is. The recommendations of the meeting asked for more private sector involvement and "experimentation with private contracting of public health services" (Purohit and Mohan 1996:452).Narasimha Rao. were ample indications that large-scale privatisation of health care was being seriously considered.V. This paper has followed a similar line of argument: while it may be too early to be categorical. The situation may be somewhat different now as it is unlikely that the United Front government will push through privatisation of health services. further. In March 1995. there. "the anticipated reduction in services implies that women may also have to allocate more time to activities that were previously at least partially provided by the state " (Government of India 1995:54-5. health activists and others was convened in Jaipur to debate a recent World Bank document. the document was hypothesising on likely fall outs. By definition. economic reform of the kind initiated by the State in 1991 is not going to reverse the trend of an overall decline in women's status. The spirit of the meeting was clearly the need for alternatives to the "fragile public health system"(ibid. the question of course is. There is no evidence in the fifty years of India's Independence that its health sector has been 'marketable'.Despite its inadequacies and shortcomings. it is clear that a structural Adjustment programmes will. the State-run health care system is heavily subsidised.

Yet.bring little profit to them. However. In this case. to recognise that theories of rights and obligations will not work "by maintaining a depersonalized. if the Indian economy is to be competitive it has to liberalise and become a part of the global nexus. becoming increasingly difficult. no such thinking seems to have influenced thinking on the social sector. At the same time it is clear that the crisis in the social sector existed prior to 1991 and a myopic. in other words. there are no indications that it will not be the same story of more funds for a battery of new targets to be achieved. Any reform should be preceded by a period of intense debate.7% of the GDP (Bidwai 1996). the critical edge. It is not difficult to see how these cuts will impinge on nutrition. there is little to suggest that the United Front government is going to adopt a position very different from its predecessors: an analysis of the Front's budgetary allocations for rural employment shows that schemes will be done to 0. it is the large bulk of the Indian population which is of little consequence to those who seek benefits through the market.31 % of the GDP from 0. apart from a political will which means business it also requires the freedom and inclination to think of options and alternatives. distancing attitude towards others" (Robinson 1997: 130). discussion and an elaboration of strategies and goals. It can be assumed that stabilisation and the structural adjustment programme were adopted after such exercises had been carried through. descriptions of the inner life of the household indicates how a complex interplay of factors determine entitlements and shares. 20 . Above all for such a commitment to be meaningful. well-being and health of the more vulnerable sections of the population.5 . However. the State and its functionaries have to acknowledge the role of civil society in providing the 'human face'.1. top-down approach which seeks refuge in allocating more funds will not work. Those in positions of authority need to develop an unblinkered approach and look beyond their traditional information brokers and panacea of well-worn methods and approaches. to reform and and its often unacceptable assumptions about the citizens of a country faced with wide-reaching re-definitions of both their public and private spaces.49%. The inability of the State to provide a workable system of health care only exacerbates the tensions experienced by underprivileged women whose daily lives are. this does not mean that the State should be free to adopt an increasingly minimalist position in areas which determine the survival of a large bulk of its population. the State has to be prepared to listen to the multiple voices which question its policies. Health care is one such area. in any case. and the State's social spending has stagnated at around 1. Clearly. At this point of time. A genuine commitment to distributive justice and equity requires much more than declining budgetary allocations.

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